More drugs, less talk for post-heart attack depression?

11 Dec

Pill Box

by Carolyn Thomas     @HeartSisters

We know that many heart patients (like me, for example), experience some degree of situational depression immediately following a cardiac event. When we seek help, that help is far more likely to come as a prescription for an antidepressant drug rather than a referral to a professional for talk therapy. In fact, talk therapy – either by itself or in combination with medication – is actually on the decline(1) while the rate of antidepressant use has increased by almost 400% in the past two decades.(2)

This is important, because we also know from 2015 research on depression published in the British Medical Journal (BMJ) that, for most people, there is no statistically significant difference in effectiveness between talk therapy and taking drugs.(3) When researchers tracked treatment outcomes for those suffering from depression, they found patients responded equally to either treatment. So why hasn’t the rate of talk therapy gone up by 400%, too?

The BMJ study’s lead author Dr. Halle Amick explained:

“We don’t think this finding is particularly surprising, because each treatment has its own evidence base that shows they’re effective in treating major depressive disorder.

“But this is one of the few studies to actually compare them head to head. And the finding is important because many doctors don’t have an understanding of cognitive behavioral therapy, and often don’t feel fully comfortable prescribing it.”

The take-away message from Dr. Amick: if a doctor doesn’t talk about psychotherapy as a treatment option, patients should be encouraged to ask about it.

This is not only a quality-of-life issue, but a depressed heart patient is unlikely to follow even the most basic of doctor’s orders like taking cardiac meds, quitting smoking, eating heart-healthy food or exercising.

Dr. Stephen Parker is an Alaska cardiac psychologist (and more importantly to me, a heart attack survivor himself). As he explains:

“As a psychotherapist, I have spent much of my work life talking with/listening to folks about their lives. I certainly believe that it can be useful and meaningful.

“As a heart patient, I have found that the cardiology industry emphasizes drugs over lifestyle, facts over feelings. It is a disturbing trend that more and more people are being treated with drugs alone.”

After being discharged from hospital, I expected to feel happy and grateful because I’d just survived a widowmaker heart attack. Instead, I felt exhausted, distressed, weepy, and unmotivated to even drag myself out of bed in the morning. I slept in my clothes. I no longer cared about basic personal hygiene like showering or washing my hair, and I no longer cared about how I looked or how I smelled. All I wanted to do was crawl back under the covers.

I tried very hard to paste on my best happy face around my family and friends, but eventually I found simply making conversation so utterly exhausting that it just seemed easier to make excuses and avoid others entirely. See also: The New Country Called Heart Disease.

I didn’t even know it at the time, but I was depressed. This type of mild to moderate depression can occur frequently after a health crisis like a heart attack, and is often known as “situational depression” or “stress response syndrome”.  It’s also what mental health professionals call an adjustment disorder that can strike in the early weeks following a traumatic life event as we struggle to make sense of something that makes no sense.

The good news is that, unlike severe clinical depression, situational depression typically tends to run its course over about a six-month period, and can often eventually fade with or without treatment.

The best-studied form of talk therapy is called cognitive-behavioral therapy, which involves examining how our thoughts affect our emotions, and learning ways to change behaviour patterns that may be negatively affecting our mental wellbeing.

Before I was discharged from hospital after that heart attack, not one person in the CCU (the hospital’s intensive care unit for heart patients) had warned me of the reality of these mental health issues. Not one cardiologist, not one nurse, not one janitor had said even one word to me about what turns out to be a very common problem – a problem that cardiologist rarely mention to their patients. See also: When are Cardiologists Going to Start Talking about Depression?

Unfortunately, many heart specialists may not have the time or the expertise to address depression, according to cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic:

“Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”

Cardiologists aren’t the only physicians ignoring mental health issues.

My (now former) family doctor was clearly reluctant to refer me to a psychotherapist despite my repeated requests for this referral. She claimed that there was “a one-year waiting list” for such appointments. (Here in Canada, appointments with registered psychologists are only partially funded through employee extended health benefits programs, while appointments with psychiatrists are fully funded through our healthcare system).

After months of taking the antidepressant drugs my doctor had prescribed, and then trying different drugs, and then higher doses of drugs (with little if any relief), I persisted, asking her again in desperation for a referral for talk therapy.

It was obvious to me that she just did not want to do this. “I suppose you want a good one?” she muttered as she scanned a long list of local psychotherapists. She told me she’d have to send out a referral request to several on the list, just to find even one professional in this whole town who would be able to squeeze me in. Within two days, I came home from the grocery store one morning to find five phone messages from five local psychotherapists, each offering me an office appointment that same week. I picked the name of a therapist within walking distance of my home, and one day later, I was seated on her couch.

One. Day. Later.

So much for that one-year waiting list . . .

Most antidepressants are being prescribed by family physicians, not by trained mental health professionals. It turns out that fewer than half of people taking more than one kind of prescribed antidepressant drugs have actually seen a mental health professional during the past year, according to a Harvard Medical School National Health and Nutrition Examination Survey.(2)

Many of us are reluctant to seek out talk therapy. As the Canadian Mental Health Association explains:

“Some people worry about asking for help because there can be stigma around mental health problems. They may believe that asking for help means admitting that something is wrong. Some people worry about how others might see them.

“Asking for help means that you want to make changes or take steps towards your new health goals.

“We should celebrate the courage it takes to speak up and make changes. Getting help is part of recovery.”

And as Dr. Katherine C. Nordal wrote in her American Psychological Association online column(4):

“Psychotherapy doesn’t need a ‘black box’ warning. It doesn’t cause common side effects, such as weight gain, nausea, sexual dysfunction or sleep disturbance. It doesn’t stop working altogether when treatment ends.

“In fact, psychotherapy arms users with a new set of problem-solving skills they can apply whenever needed.”

“This can’t be surprising to anyone who has been watching trends over the last decade. Insurance companies prefer that patients receive medication, which they can control, over psychotherapy, which is harder to control.

“Every day, anyone who watches television or reads popular magazines encounters at least one and usually several ads for one or another of the heavily advertised antidepressants or atypical antipsychotics. Nowhere in any of those ads is it even suggested that the combination of psychotherapy and medication has been shown again and again to be superior to medications alone.

“I have heard physicians say that patients do not want to take the time for psychotherapy, that they prefer to take meds instead. Well, of course they do – because that is what they are being taught to do.

“There are no ads for psychotherapy. No public service announcements about the value of talking to another human being as a way to deal with depression or other emotional ills. The only advocates for the value of psychotherapy are psychotherapists – and our voice is way too muted to be heard over the din of the psycho-pharmacological  messages.”

It’s important to keep in mind that most published research favouring the use of antidepressant drugs has been funded by the drug companies that manufacture those drugs.

But it’s also important to mention here that antidepressant drugs can be very effective in treating debilitating symptoms of severe depression for some people.

And Dr. Parker sums it up like this:

“Research suggests that drug therapy combined with talk therapy is more effective than drug therapy alone. Yet the trend is against this. 

“What will it take to put the ‘heart’ back into medicine?”

  1. M. Olfson et al, American Journal of Psychiatry, online August 4, 2010.
  2. L. Pratt et al, “Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008,” NCHS Data Brief No. 76, October 2011.
  3. H. Amick et al, “Comparative Benefits and Harms of Second Generation Antidepressants and Cognitive Behavioral Therapies in Initial Treatment of Major Depressive Disorder: Systematic Review and Meta-analysis,”
  4. K. Nordal, “Where Has All the Psychotherapy Gone?” American Psychologist Association: Perspectives on Practice, November 2010, Vol 41, No. 10, 17.

Q:  Has your physician supported your requests for talk therapy referrals?

See also:

 

13 Responses to “More drugs, less talk for post-heart attack depression?”

  1. Dillan Marsh December 12, 2016 at 7:35 am #

    This is a very informative post about depression and heart attack, Carolyn, I couldn’t have found it at a better time.

    I know I struggle with stress at times, the mindful thinking is very helpful though. I try to but this article was a great reminder. Also to just take a few minutes daily to truly relax, meditate, do yoga or whatever works best, is also a great reminder – something I need to start doing again.

    Liked by 1 person

    • Carolyn Thomas December 12, 2016 at 1:16 pm #

      Thanks for reminding us all, Dillan – especially for such a good point about taking a few minutes every day to do some kind of focused, calming activity. Sometimes we believe that in order to unwind, we need to take an entire spa day – but every little bit helps, doesn’t it?

      Like

  2. Dr. Leslie Kernisan December 12, 2016 at 2:59 am #

    Thanks Carolyn for bringing up this really important issue. I hope this helps more people find talk therapy and other non-drug ways to manage depression.

    There is really no substitute for people doing a little research on their own regarding treatment options. Fortunately support groups and patient communities can help with this.

    I also agree that it’s often too hard for people to find therapy, even if they think to ask.

    Liked by 1 person

    • Carolyn Thomas December 12, 2016 at 6:05 am #

      Hello, Dr. K! Thank you for weighing in here. Your last sentence reminded me that many patients have also found helpful support in talking to a pastor, a social worker, or trained peer counselor. But they have to 1. identify the need to seek out such help, and 2. come forward to actually ask for it. Both are difficult during the depths of depression. That’s why GPs and cardiologists can be so crucially important in encouraging their patients to get help (including talk therapy) – NOT discouraging it as my own ex-GP did. Local mental health facilities often have lists of available resources; copies of these should be in every doctor’s waiting room!

      Like

  3. Joyce December 11, 2016 at 9:49 am #

    Interesting. I guess I had adjustment disorder on top of my life long PTSD. It is a shame she does not address hypnosis, and other alternative methods like tapping that worked miracles for me.

    Plus emailing with you all the time!! You are a good listener with lots of constructive suggestions too!! My daily therapist! haha

    Liked by 1 person

    • Carolyn Thomas December 11, 2016 at 5:34 pm #

      Hello Joyce – you’re right, there are a number of non-drug treatments for depression, as I wrote about here. (Personally, I’ve always believed that brisk walking – in addition to my talk therapy sessions – contributed significantly to improving my emotional health). This particular BMJ study happened to focus on a head-to-head comparison of talk therapy vs antidepressant drugs. PS Maybe I should be adding “daily therapist” to my business cards? 😉

      Like

  4. The Accidental Amazon December 11, 2016 at 8:09 am #

    Carolyn, I can’t tell you how frustrating it is for me to be seeing a homecare patient with any kind of mental illness, never mind the more common forms of depression or anxiety, and to try to help them get the right treatment.

    We usually have to start by sending a patient to their primary care doc, most of whom do not really have a clue how to identify the symptoms, and do not even bother to use the standardized questionnaires that are available (that we use ourselves in homecare) to help them. Then, even if they bother to prescribe a medication, it’s often not the right one, and there is very little, if any, follow-up to make sure it works.

    If it is clear that the patient needs a referral to an expert, here in the US, there is a dearth of decent psychiatrists, nurse practitioners, psychologists and others who know what they are doing and are good at it, so it can be hard to get someone seen.

    Then, if counseling is recommended, many patients don’t want to go to counseling, and if they are getting homecare, it is often physically challenging for them to go to regular appointments, even if they are willing to. We have one service agency that provides homecare treatment for mental illness, and they are overloaded.

    Plus, it can be tricky sometimes to distinguish between situational depression (sometimes called dysthymia) from more chronic, recurring depression. A skilled clinician is needed to get a full history from the patient, to tease out whether their current depression is part of a longer pattern. I did counseling for years to help with my own depression, long before the advent of SSRIs, and developed a good bag of tricks to deal with it. But it was a constant struggle. Finally, when a year full of personal tragedy kicked it off again, I was able to try Zoloft, which was nothing short of a miracle for me. I ended up doing counseling again, too, because drugs alone do not help you recognize feelings and develop coping strategies. I definitely agree that both together are better than the drug alone.

    Years later, after having breast cancer, I began taking large doses of vitamin D3, which was recommended for those with estrogen positive breast cancer. My blood level vitamin D3 was indeed low, and it took about six months of D3 for it to get normal. I also then discovered, accidentally, that I no longer needed to take Zoloft. I was apparently one of those people for whom D3 mitigated whatever neurochemistry was involved in my depression, and fixed it. I still take D3, and I still feel good, but I don’t say this would work for everyone. But vitamin D levels are another thing that doctors don’t always routinely check, and should.

    Thanks for another great post.
    xo, Kathi

    P.S. So glad to see from your FB page that you are enjoying grandma-hood. Now, there’s a great antidepressant!

    Liked by 1 person

    • Carolyn Thomas December 11, 2016 at 8:17 am #

      Thank you for such a comprehensive overview of this issue, Kathi. So many good points. And yes, I do recommend grandbabies as a cure-all. On the day she was born, one of my readers told me: “This precious child will be better for your heart than anything your cardiologist could prescribe!”

      Like

  5. Deborah Mayer December 11, 2016 at 5:43 am #

    I am so motivated by you and your posts. I find that your experiences almost exactly mirror mine. I had quint CABG (open heart bypass surgery) on Feb 19th. While in CVSICU and after extubation, I knew I had to make a plan to motivate my recovery. I had the nurses place me in sitting position in bed, finally moved to recliner, my reasoning being facilitate movement without increase of discomfort – also encouraged the many respiratory treatments post op.

    When I was up to walk with nurses, I told the nurse my goal of distance before walk started. This made ME feel I had control and choice. Once moved, I did not get into my bed. I had a sheet placed over the recliner in my room. Once again, this would keep my legs more elevated than in the bed, plus being in better position to easily move to ambulate.

    My discharge instructions were so minimal. The surgeon was amazing in directions for home and surgical wound care, meds, diet, etc, but no mention of mood swings. I live alone but had a friend that would daily check on me as well as do household ‘musts’. I also had my son, his wife and 4 grandkids come for 4 days.. tiring, but it was important to have people around. It motivated me further to get up, fix my hair and dress.

    It also helped that the surgeon had ordered visiting RN daily x 14 days. (The male nurse was handsome and kind. That surely helped motivate me!! LOL I have rambled…)

    What is relevant to your article is that there is zero discussion of the mood swings after a coronary event. They, the moods/depression, must be addressed before the patient is discharged. Patients should be encouraged to make a plan for their own recovery, and this should be discussed and encouraged.

    A patient informed assists the physician. A patient informed and motivated is a positive experience, but it requires teamwork.

    I am so thankful for your posts. They help me immensely. I struggle with a bit of “pump head” from time to time, and some depression, but I know the drs don’t understand all and sometimes a person just has to ‘suck it up’ and make their own recovery.
    Deborah Mayer

    Liked by 1 person

    • Carolyn Thomas December 11, 2016 at 6:02 am #

      Thanks so much for your kind words, and for sharing your perspective here. I’m so impressed that very early on you were able to make a plan to motivate your (physical) recovery. What would have really helped you was to be prepared before hospital discharge for the very common experience of emotional/mood/depression issues that are essentially ignored by most healthcare professionals.

      Most patients simply don’t see it coming, which makes us feel even worse if/when it does. In my opinion, a mental health discussion pre-discharge is every bit as important to heart patients as that discussion about wound care is. You’re so right about being an informed patient. Best of luck to you, Deborah…

      Like

  6. Bonnie Winters December 11, 2016 at 5:01 am #

    Great article Carolyn.
    I was diagnosed with Coronary Microvascular Disease (CMVD) about 3 years ago and went through a mild depression at the time. I had been through psychotherapy (talk therapy) for a different issue 20 years ago so I knew its value. At that time, the therapist taught me skills I needed to create a strong support network which I was able to use to help me through the heart related depression. I found others who had gone through similar experiences and talked and asked questions. The more I talked about what I was experiencing, the better I felt and less alone.

    Then just last year, I suffered a severe spiral fracture of my lower femur which required major surgery and rehab. Once again, depression struck. Now I was dealing with two things, the immobility of the fracture and the increase of CMVD symptoms because of exertion and physical stress on my body from the break. Once again, the lessons learned have helped me to find and benefit from talk therapy in the form of supportive people who had experienced similar life events. Not only have I benefited from this kind of support group, I have made myself available to others who need to talk. It has been a win-win situation for me.

    Insurance may not cover psychotherapy, but support groups are usually free. No one recommends those either!

    Liked by 1 person

    • Carolyn Thomas December 11, 2016 at 5:18 am #

      Thanks Bonnie for this valuable reminder that, as Dr. Nordal mentioned in this post, talk therapy not only provides immediate assistance, but it can arm participants with useful coping tools to help us manage future health crises. Support groups – either in person or online – should also be on that referral list! Inspire’s WomenHeart online community, for example, is free to join, open 24/7 and has over 26,000 members all living with heart disease.

      Like

Trackbacks/Pingbacks

  1. Post of the Week: Psychology Research Digest - December 19, 2016

    […] …This article explains how depression following a heart attack is treated. There’s a bias towards giving people drugs for this, in part because in Canada, as in many other countries, access to a psychiatrist who prescribes the tablets is easier than to a psychotherapist who is able to talk about the problem. The article makes a case for greater access to talking therapy. […]

    Like

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